1.
Semen analysis as per WHO 2010
and clinical implications
Sandro C. Esteves, MD, PhD
Medical Director, ANDROFERT
Campinas, Brazil
Andrology Workshop
ISAR 2015 – Chennai

2.
Agenda
Semen analysis overview
New WHO reference values
Implications to clinical management
Proposal of a new report template
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 2
2015
ANDROFERT

3.
Semen analysis is the most used
biomarker to predict fertility potential
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 3
2015
ANDROFERT

4.
Routine Semen Analysis
l Physical characteristics of ejaculate
l Sperm count
l Sperm motility
l Sperm morphology
l Sperm vitality
l Leukocyte count
l Additional tests (fructose, etc)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 4
2015
ANDROFERT

5.
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 5
2015
ANDROFERT
l Standardization
Pre-analytical
Analytical
Post-analytical
l Quality Control
Certification, Validation
l Reference values
WHO Manual
Where to do it?

6.
l Pre-analytical
Instructions for collection
Rejection criteria
Abstinence period
l Analytical
Standard operating procedures
l Post-analytical
Report
Is the lab good enough?
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 6
2015
ANDROFERT

7.
SOP
format
-­‐
Clinical and Laboratory
Standards Institute (CLSI)
I.
General
informa3on:
• Document
number
• Revision
number
and
date
• Effec3ve
date
of
the
document
• Number
of
pages
• Title,
to
include
name
of
analyte,
type
of
specimen,
and
method/assay
and/or
instrumenta3on
• Principle
and/or
purpose
• Scope
II.
Pre-­‐analy3c
informa3on:
• Specimen
requirements/collec3on
methods
III.
Analy3c
informa3on:
• Reagents,
standards,
controls,
and
media
used
• Instrumenta3on,
Calibra3on
procedures
• QC
(nega3ve/posi3ve
control
if
required)
• Procedural
steps
• AMachments
(e.g.,
product
inserts)
IV.
Post-­‐analy3c
informa3on:
• Calcula3ons
• Repor3ng
results
• Reference
ranges/cri3cal
values
• Limita3ons
• References
V.
Other:
• Defini3ons
• Distribu3on
• Author
• Approval
signatures
and
dates
• Document
change
history
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 7
2015
ANDROFERT

8.
Report format - CLSI
• Either
the
par3cipant’s
name
and/or
a
unique
par3cipant
iden3fier
• Name
and
address
of
laboratory
loca3on
• Date
and
3me
of
specimen
receipt
into
the
laboratory
• Assay
report
date
• Name
of
the
test
performed
• Specimen
source
(e.g.,
semen)
• Assay
result
and,
if
applicable,
units
of
measurement
and/or
interpreta3on
• Reference
ranges
• Any
informa3on
regarding
the
condi3on
and
disposi3on
of
specimens
that
do
not
meet
• Laboratory's
criteria
for
acceptability
• Records
and
dates
of
all
assays
performed
• The
iden3ty
of
the
personnel
who
performed
the
test(s)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 8
2015
ANDROFERT

9.
WHO Manual: it is free!
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 10
2015
ANDROFERT

10.
1980 1987 1992 1999
Volume (mL) ND ≥2 ≥2 ≥2
Count (106/mL) 20-200 ≥20 ≥20 ≥20
Total count (106) ND ≥40 ≥40 ≥40
Motility (%) ≥ 60 ≥50 ≥50 ≥50
Progressive (%) ≥ 2 ≥25% ≥25% (a) ≥25% (a)
Vitality (%) ND ≥50 ≥75 ≥75
Morphology (%) 80.5 ≥50 ≥30 (14)*
Leukocytes (106/mL) <4.7 <1.0 <1.0 <1.0
*Strict
criteria
(Tygerberg);
Esteves
et
al.
Urology
2012
WHO
reference
values
changed
2010
≥1.5
≥15
≥39
≥40
≥32%
≥58
≥4*
1.0
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 11
2015
ANDROFERT

11.
Urology 2012; 79(1):16-22
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 12
2015
ANDROFERT

12.
How the references were obtained
§ 1953 specimens
§ Recent fathers (Time-to-Pregnancy ; TTP) ≤ 12 mo.
§ Data extracted from 5 studies
§ Laboratories with QC
§ Morphology by Kruger’s method
Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker H, Behre H, Haugen
T, Kruger T, Wang C, Mibzvo MT, Vogelsong K
World Health Organization reference values for human semen characteristics.
Hum Reprod Update 16: 231-245, 2010.
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 13
2015
ANDROFERT

13.
Percentile
5% 50%* 95%
Volume (mL) 1.5 3.7 6.8
Count (x106/mL) 15.0 73.0 213.0
Total count (x106) 39.0 255.0 802.0
% Motile 40 61 78
% Progressive motility 32 55 72
% Normal (Kruger) 4 15 44
% Alive 58 79 91
Cooper et al: World Health Organization reference values for human semen characteristics.
Hum Reprod Update 16: 231-245, 2010
How the references were obtained

14.
Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on
Diagnosis and Treatment of Subfertile Men
Esteves, Zini, Aziz et al, Urology, in press
Columbia
USA
Melbourne
Australia
Turku
Finland
Oslo
Norway
Edimburgh
UK
Paris
France
Copenhagen
Denmark
Esteves, 15

15.
WHO 2010: What changed?
• Percentile “5” to determine lower cutoff limits
• Strict (Kruger) morphology
• Single specimen per individual
Method
• Recent fathers (known TTP)
• Limited geographic location
Studied population
Esteves et al. Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on
Diagnosis and Treatment of Subfertile Men. Urology 2012; 79(1):16-22.
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 16
2015
ANDROFERT

16.
How do the new references impact
clinical management?
Referral
Treatment
ART
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 17
2015
ANDROFERT

17.
Parameters Patient
Volume (mL) 2.3
Count (106/mL) 16.5
Progressive motility (%) 40
Vitality(%) 65
Morphology (%) 9
Referral Deferment
References
1999 2010
≥ 2 ≥ 1.5
≥ 20 ≥ 15
≥ 50 ≥ 32
≥ 75 ≥ 58
(14) ≥ 4
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 18
2015
ANDROFERT

18.
987 couples with infertility
duration > 12 months
Esteves, Int Braz J Urol 2014
53% reclassification
due to morphology
Semen Analysis Report
Abnormal
results as per
WHO 1999
38.7%
Redefined as
“Normal” as per
WHO 2010
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 19
2015
ANDROFERT

19.
Cause of infertility in up to 35% men
Guidelines’ recommendation:
Palpable (clinical)
Abnormal semen parameters
Male Infertility Best Practice Policy Committee - AUA, 2004;
European Association of Urology. Guidelines on Male Infertility, 2010.
Varicocele Treatment
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 20
2015
ANDROFERT

20.
87.8
49.9
37.4
62.9 56 55.6
8.4 7.3 6.1
No varicocele Grade 2 Varicocele Grade 3 Varicocele
Adolescents with and without Varicocele
Count (million/mL) Progressive motility (% a+b) Morphology (%)
Mori et al. Does varicocele grade determine extent of alteration to
spermatogenesis in adolescents? Fertil Steril 90: 1769-1773, 2008.
P=0.003 P<0.001
Varicocele
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 21
2015
ANDROFERT

21.
ICSI
IVF & IUI
ART
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 22
2015
ANDROFERT

22.
Semen analysis alone should not be used
to counseling or treatment indication
l Semen characteristics that
discriminate fertile from infertile men
not well defined
l Biological variability
l Not account for sperm dysfunctions
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 23
2015
ANDROFERT

23.
History taking,
physical examination,
endocrine profile and
laboratory sperm
function testing are
minimum standards
Esteves, et al 2011; 2012; 2014
Male infertility evaluation goes far
beyond a simple semen analysis
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 24
2015
ANDROFERT

24.
Frequency of elevated SDF in men with
unexplained infertility
Elevated
SDF
(27%)
Androfert; N=987
Elevated
SDF
(27%)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 25
2015
ANDROFERT

25.
Proposal for a new report template
Esteves,
Int
Braz
J
Urol
2014;
40:443-­‐53
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 26
2015
ANDROFERT

26.
Thank
you
धन्यवाद Obrigado
hMp://www.slideshare.net/
sandroesteves